Author + information
- Received December 22, 2016
- Revision received January 19, 2017
- Accepted January 26, 2017
- Published online April 26, 2017.
- Jie Fan, MDa,
- Bing Yang, MDb,∗ (, )
- Weizhu Ju, MDb,
- Hongwu Chen, MDb,
- Fengxiang Zhang, MDb,
- Gang Yang, MDb,
- Mingfang Li, MDb,
- Kai Gu, MDb,
- Zidun Wang, MDb,
- Hailei Liu, MDb,
- Xin Xie, MDb,
- Kejiang Cao, MDb and
- Minglong Chen, MDb
- aDivision of Cardiology, The First People’s Hospital of Yunnan Province, Kunming, Yunnan Province, People’s Republic of China
- bDivision of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, People’s Republic of China
- ↵∗Address for correspondence:
Dr. Bing Yang, Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, 210029 Nanjing, Jiangsu Province, People’s Republic of China.
A 58-year-old man presented with incessant atrial flutter (AFL) (Figure 1A); he had twice undergone unsuccessful attempts at ablation of the cavotricuspid isthmus (CTI) and was referred for ablation. Counterclockwise CTI-dependent AFL was verified by activation mapping (Figure 1B and 1C) and entrainment mapping. Extensive ablation using a 56-hole irrigated-tip catheter (ThermoCool SF, Biosense Webster, Inc., Diamond Bar, California, USA), with a power of 40 W, failed to terminate the tachycardia. The AFL was terminated undesignedly using catheter manipulation. Venography of the inferior vena cava (IVC) showed a prominent left hepatic vein (LHV) just beneath the CTI (Figure 1D and Online Video 1). A 5-F flow-directed temporary pacing balloon catheter (PACEL; St. Jude Medical, St. Paul, Minnesota) and a 6-F angiographic catheter (MPA2; Cordis, Johnson & Johnson, Miami, Florida) were advanced into the LHV simultaneously. After the balloon was inflated, occlusion of the LHV was checked with a contrast medium injection (Figure 1D). CTI conduction block was achieved 1.83 s after the onset of the subsequent radiofrequency application (Figure 1E) at the IVC end of the CTI with the same power setting. Bidirectional CTI block was confirmed at the end of the procedure. Computed tomographic venography was performed later, which clearly demonstrated the vicinity of the CTI and the ostium of the LHV. At the 19-month follow-up, the patient was free of atrial arrhythmias. This case illustrates that the heat-sink effect of LHV may act as a newly recognized obstacle to CTI block and that LHV occlusion can facilitate a difficult CTI ablation.
For a supplemental video and its legend, please see the online version of this article.
Dr. Fan was supported by a grant from the Key Projects of Science and Technology of Yunnan Province (grant no. 2014RA069). Drs. B Yang and ML Chen were supported by the Program for Development of Innovative Research Team in the First Affiliated Hospital of Nanjing Medical University (no. IRT-004).
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 22, 2016.
- Revision received January 19, 2017.
- Accepted January 26, 2017.
- 2017 American College of Cardiology Foundation